Provider Demographics
NPI:1003233412
Name:ROSS, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2366
Mailing Address - Country:US
Mailing Address - Phone:323-573-1128
Mailing Address - Fax:310-645-0023
Practice Address - Street 1:11616 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2366
Practice Address - Country:US
Practice Address - Phone:323-573-1128
Practice Address - Fax:310-645-0023
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA708 INTERN NUMBER101YP2500X
CA77598 INTERN NUMBER106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist